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Dental Pain

Matt DeLaney MD
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25:54
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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01:05

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EM:RAP 2017 September Written Summary 760 KB - PDF

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Michael V. PA -

I've occasionally seen other clinicians give a dose of dexamethasone for a patient with pulpitis. Intuitively this makes sense as it is an inflammatory process. Is there any data to support this practice?

Matthew D. -

I can't find any data looking at this approach but it makes sense from a physiologic standpoint. Steroids aren't a no-risk drug but for most patients who are otherwise healthy this may be something worth trying.
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Matthew D. -

I can't find any data looking at this approach but it makes sense from a physiologic standpoint. Steroids aren't a no-risk drug but for most patients who are otherwise healthy this may be something worth trying.

Michael R. -

Thank you for mentioning our clinical trial of penicillin vs placebo for dental pain (Runyon, MS et al. Efficacy of penicillin for dental pain without overt infection. Acad Emerg Med. 2004 Dec;11(12):1268-71 PMID: 15576515). One correction: contrary to what was stated in the overview, these absolutely were ED patients. Everyone we enrolled presented to our ED with dental pain, but without evidence of overt infection on exam by an emergency medicine resident or attending physician.

Jon M. -

Matt: Nice talk. Non traumatic dental pain (NTDP) is an interest of mine, and I enjoyed hearing someone else talk about it for once.

There's multiple issues at play in regards to NTDP. The only issue that I would tread lightly on is in regards to antibiotic use. I changed my practice to what you suggested 5 years ago after giving a grand rounds on the subject, yet I've reverted back.

We rarely have objective evidence to say that our patient has pulpitis, but without bitewings we can't see if there's an apical abscess forming. Even if there were an abscess forming, we all know that antibiotics don't treat abscesses and that our patient will need definitive treatment, often a root canal or extraction, etc.. However, having worked with dentists in the National Guard for the past 8 years (they taught be how to extract teeth - super fun!), I realize that dentists don't read the Cochran review demonstrating the lack of utility in antibiotics. In fact, many will not perform a procedure until the infection has "cooled off" a bit. Anecdotally, I've had patients bounce back a day later because the dentist wouldn't see them until they had been placed on antibiotics.

In most communities getting someone without money or insurance is literally impossible. They might wait for two weeks. During this time, if they had an apical abscess forming from bad dental caries, then that infection could be progressing to something more dangerous like Ludwigs. Furthermore, when their number gets called and it's their turn to sit in the dentist chair, I want the dentist to have no excuses in regards to why they won't treat them. That's why I have personally reverted back to having a low threshold to give some antibiotics to those with NTDP.

I think dental extractions should be in the wheelhouse of the emergency physician. I wrote an article to Annals about it a few years back, but clearly they don't like that ball of wax. They task shift that to some family medicine residents back in our former homeland Maine - http://www.nytimes.com/2009/03/03/us/03dentist.html?_r=0 - let me know when you want to start a dental training program.

Jonathan G. -

It would nice to an EM-RAP HD video for these blocks. Great segment. I really appreciated it.

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